Download Form SSA-1695-F3 Identifying Information for Possible Direct Payment of Authorized Fees
Form SSA-1695-F3 Instructions
Detailed instructions for completing the SSA Form 1695-F3 and a Privacy Act Statement are provided on the second and third pages of the form. Step-by-step filling out instructions are provided below.
- Specify the name and Social Security number (SSN) of the client you represent;
- If the claim filed is based on the record of a person other than your client, indicate their name and SSN (wage earner);
- Specify, for which type of benefits you represent your client by checking the appropriate box;
- Indicate your SSN, mailing address, and name as shown on your Social Security card; if you have changed your last name for to any reason, ask the officials at your local SSA to change it in your Social Security record as well;
- If you are representing your client as an employee or partner of a company or other business entity, provide the Employer Identification Number (EIN) of this business entity; the EIN you provide allows the SSA to send this business a Form 1099-MISC; it is required for tax purposes;
- If you represent any other clients regarding this claim, provide their names and SSNs on the bottom part of the form; if you represent more than five clients, provide their information on a separate sheet and attach it to this form.
Send or take the completed form to your local Social Security office. Find the address of your local office through the SSA official website or by calling the SSA at the phone number indicated on the third page of the form. The list of the Social Security offices is provided in the telephone directory under U.S. Government agencies.